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Archive for November, 2014

Trigger finger is a painful condition that causes the fingers or thumb to catch or lock when bent. In the thumb its called trigger thumb.

Trigger finger happens when tendons in the finger or thumb become inflamed. Tendons are tough bands of tissue that connect muscles and bones. Together, the tendons and muscles in the hands and arms bend and straighten the fingers and thumbs.

A tendon usually glides easily through the tissue that covers it (called a sheath) because of a lubricating membrane surrounding the joint called the synovium. Sometimes a tendon may become inflamed and swollen. When this happens, bending the finger or thumb can pull the inflamed tendon through a narrowed tendon sheath, making it snap or pop.

What Causes Trigger Finger?

Trigger finger can be caused by a repeated movement or forceful use of the finger or thumb. Rheumatoid arthritis, gout, and diabetes also can cause trigger finger. So can grasping something, such as a power tool, with a firm grip for a long time.

Who Gets Trigger Finger?

Farmers, industrial workers, and musicians often get trigger finger since they repeat finger and thumb movements a lot. Even smokers can get trigger thumb from repeated use of a lighter, for example. Trigger finger is more common in women than men and tends to happen most often in people who are 40 to 60 years old.

What Are the Symptoms of Trigger Finger?

One of the first symptoms of trigger finger is soreness at the base of the finger or thumb. The most common symptom is a painful clicking or snapping when bending or straightening the finger. This catching sensation tends to get worse after resting the finger or thumb and loosens up with movement.

In some cases, the finger or thumb locks in a bent or straight position as the condition gets worse and must be gently straightened with the other hand.

How Is Trigger Finger Diagnosed?

Trigger finger is diagnosed with a physical exam of the hand and fingers. In some cases, the finger may be swollen and there may be a bump over the joint in the palm of the hand. The finger also may be locked in bent position, or it may be stiff and painful. No X-rays or lab tests are used to diagnose trigger finger.

How Is Trigger Finger Treated?

Conservative treatment

Most trigger digits in adults can be managed successfully with local steroid injections and splinting. Oral or topical pharmacologic measures have not been demonstrated to be effective.

The outcome of conservative treatment for pediatric trigger thumb is somewhat controversial. A report by Baek et al on the natural history of this condition demonstrated after a follow-up period of 5 years or more in patients who received no treatment for pediatric trigger thumb, complete resolution of flexion deformity occurred in 66 out of 87 thumbs (75.9%), and partial improvement occurred in the remaining 21 thumbs.

Another study, by Lee et al, reported that extension splinting for 12 weeks led to improvement in 71% of thumbs, compared with 23% improvement in patients not receiving any treatment. See also the current recommendations described by Ogino.

Surgical release

The chief indications for surgical management of trigger finger (TF) are as follows:

Failure of splinting and/or injection treatment

Irreducibly locked TF

Trigger thumb in infants (without surgical release, these infants are likely to develop a fixed flexion deformity of the interphalangeal [IP] joint)

Although the results of percutaneous release are well established, the open technique is absolutely essential for the thumb or little finger or in the presence of proximal interphalangeal (PIP) contractures. Percutaneous release should be reserved for the index, middle, and ring fingers.

In a study from Oxford comparing percutaneous and open surgical methods, both procedures displayed similar effectiveness and proved superior to conservative corticosteroid-injection treatment regarding trigger cure and relapse rates.

In children, triggering has varying causes. Release of the A1 pulley alone does not always correct the problem. Additional treatment (eg, resection of 1 or both limbs of the flexor digitorum superficialis [FDS] tendon, A3 pulley release) may be required and is recommended in rheumatoid arthritis (RA) tenosynovitis.

In infants, the nodule on the flexor pollicis longus (FPL) tendon can be resected with good results. Corticosteroid injections are generally not helpful in these cases of trigger thumb.

How Long Does Recovery From Trigger Finger Take?

The time it takes to recover from trigger finger depends on how bad it is. The choice of treatment also affects recovery. For example, splinting may be necessary for six weeks. But most patients with trigger finger recover within a few weeks by resting the finger and using anti-inflammatory drugs.

Carpal tunnel syndrome occurs when the median nerve, which runs from the forearm into the palm of the hand, becomes pressed or squeezed at the wrist. The median nerve controls sensations to the palm side of the thumb , as well as impulses to some small muscles in the hand that allow the index finger and thumb to move. The carpal tunnel – a narrow, rigid passageway of ligament and bones at the base of the hand – houses the median nerve and tendons. Sometimes, thickening from irritated tendons or other swelling narrows the tunnel and causes the median nerve to be compressed. The result may be pain, weakness, or numbness in the hand and wrist, radiating up the arm. Although painful sensations may indicate other conditions, carpal tunnel syndrome is the most common and widely known of the entrapment neuropathies in which the body’s peripheral nerves are compressed or traumatized.

What are the symptoms of carpal tunnel syndrome?

Symptoms usually start gradually, with frequent burning, tingling, or numbness in the palm of the hand and the fingers, especially the thumb and the index and middle fingers. Some carpal tunnel sufferers say their fingers feel useless and swollen, even though little or no swelling is apparent. The symptoms often first appear in one or both hands during the night, since many people sleep with flexed wrists. A person with carpal tunnel syndrome may wake up feeling the need to “shake out” the hand or wrist. As symptoms worsen, people might feel tingling during the day. Decreased grip strength may make it difficult to form a fist, grasp small objects, or perform other manual tasks. In chronic and/or untreated cases, the muscles at the base of the thumb may waste away. Some people are unable to tell between hot and cold by touch.

What are the causes of carpal tunnel syndrome?

Carpal tunnel syndrome is often the result of a combination of factors that increase pressure on the median nerve and tendons in the carpal tunnel, rather than a problem with the nerve itself. Most likely the disorder is due to a congenital predisposition – the carpal tunnel is simply smaller in some people than in others. Other contributing factors include trauma or injury to the wrist that cause swelling, such as sprain or fracture; overactivity of the pituitary gland; hypothyroidism; rheumatoid arthritis; mechanical problems in the wrist joint; work stress; repeated use of vibrating hand tools; fluid retention during pregnancy or menopause; or the development of a cyst or tumor in the canal. In some cases no cause can be identified.

There is little clinical data to prove whether repetitive and forceful movements of the hand and wrist during work or leisure activities can cause carpal tunnel syndrome. Other disorders such as bursitis and tendonitis have been associated with repeated motions performed in the course of normal work or other activities.. Writer’s cramp may also be brought on by repetitive activity.

Who is at risk of developing carpal tunnel syndrome?

Women are three times more likely than men to develop carpal tunnel syndrome, perhaps because the carpal tunnel itself may be smaller in women than in men. The dominant hand is usually affected first and produces the most severe pain. Persons with diabetes or other metabolic disorders that directly affect the body’s nerves and make them more susceptible to compression are also at high risk. Carpal tunnel syndrome usually occurs only in adults.

The risk of developing carpal tunnel syndrome is not confined to people in a single industry or job, but is especially common in those performing assembly line work – manufacturing, sewing, finishing, cleaning, and meat, poultry, or fish packing. In fact, carpal tunnel syndrome is three times more common among assemblers than among data-entry personnel.

How is carpal tunnel syndrome diagnosed?

Early diagnosis and treatment are important to avoid permanent damage to the median nerve. A physical examination of the hands, arms, shoulders, and neck can help determine if the patient’s complaints are related to daily activities or to an underlying disorder, and can rule out other painful conditions that mimic carpal tunnel syndrome. The wrist is examined for tenderness, swelling, warmth, and discoloration. Each finger should be tested for sensation, and the muscles at the base of the hand should be examined for strength and signs of atrophy. Routine laboratory tests and X-rays can reveal diabetes, arthritis, and fractures.

Physicians can use specific tests to try to produce the symptoms of carpal tunnel syndrome. In the Tinel test, the doctor taps on or presses on the median nerve in the patient’s wrist. The test is positive when tingling in the fingers or a resultant shock-like sensation occurs. The Phalen, or wrist-flexion, test involves having the patient hold his or her forearms upright by pointing the fingers down and pressing the backs of the hands together. The presence of carpal tunnel syndrome is suggested if one or more symptoms, such as tingling or increasing numbness, is felt in the fingers within 1 minute. Doctors may also ask patients to try to make a movement that brings on symptoms.

Often it is necessary to confirm the diagnosis by use of electrodiagnostic tests. In a nerve conduction study, electrodes are placed on the hand and wrist. Small electric shocks are applied and the speed with which nerves transmit impulses is measured. In electromyography, a fine needle is inserted into a muscle; electrical activity viewed on a screen can determine the severity of damage to the median nerve. Ultrasound imaging can show impaired movement of the median nerve. Magnetic resonance imaging (MRI) can show the anatomy of the wrist but to date has not been especially useful in diagnosing carpal tunnel syndrome.

How is carpal tunnel syndrome treated?

Treatments for carpal tunnel syndrome should begin as early as possible, under a doctor’s direction. Underlying causes such as diabetes or arthritis should be treated first. Initial treatment generally involves resting the affected hand and wrist for at least 2 weeks, avoiding activities that may worsen symptoms, and immobilizing the wrist in a splint to avoid further damage from twisting or bending. If there is inflammation, applying cool packs can help reduce swelling.

Non-surgical treatments

Drugs – In special circumstances, various drugs can ease the pain and swelling associated with carpal tunnel syndrome. Nonsteroidal anti-inflammatory drugs, such as aspirin, ibuprofen, and other nonprescription pain relievers, may ease symptoms that have been present for a short time or have been caused by strenuous activity. Orally administered diuretics (“water pills”) can decrease swelling. Corticosteroids (such as prednisone) or the drug lidocaine can be injected directly into the wrist or taken by mouth (in the case of prednisone) to relieve pressure on the median nerve and provide immediate, temporary relief to persons with mild or intermittent symptoms. (Caution: persons with diabetes and those who may be predisposed to diabetes should note that prolonged use of corticosteroids can make it difficult to regulate insulin levels. Corticosteroids should not be taken without a doctor’s prescription.) Additionally, some studies show that vitamin B6 (pyridoxine) supplements may ease the symptoms of carpal tunnel syndrome.

Exercise – Stretching and strengthening exercises can be helpful in people whose symptoms have abated. These exercises may be supervised by a physical therapist, who is trained to use exercises to treat physical impairments, or an occupational therapist, who is trained in evaluating people with physical impairments and helping them build skills to improve their health and well-being.

Alternative therapies – Acupuncture and chiropractic care have benefited some patients but their effectiveness remains unproved. An exception is yoga, which has been shown to reduce pain and improve grip strength among patients with carpal tunnel syndrome.

Surgery

Carpal tunnel release is one of the most common surgical procedures in the United States. Generally recommended if symptoms last for 6 months, surgery involves severing the band of tissue around the wrist to reduce pressure on the median nerve. Surgery is done under local anesthesia and does not require an overnight hospital stay. Many patients require surgery on both hands. The following are types of carpal tunnel release surgery:

Open release surgery, the traditional procedure used to correct carpal tunnel syndrome, consists of making an incision up to 2 inches in the wrist and then cutting the carpal ligament to enlarge the carpal tunnel. The procedure is generally done under local anesthesia on an outpatient basis, unless there are unusual medical considerations.

Endoscopic surgery may allow faster functional recovery and less postoperative discomfort than traditional open release surgery. The surgeon makes two incisions (about ½ inch each) in the wrist and palm, inserts a camera attached to a tube, observes the tissue on a screen, and cuts the carpal ligament (the tissue that holds joints together). This two-portal endoscopic surgery, generally performed under local anesthesia, is effective and minimizes scarring and scar tenderness, if any. Single portal endoscopic surgery for carpal tunnel syndrome is also available and can result in less post-operative pain and a minimal scar. It generally allows individuals to resume some normal activities in a short period of time.

Although symptoms may be relieved immediately after surgery, full recovery from carpal tunnel surgery can take months. Some patients may have infection, nerve damage, stiffness, and pain at the scar. Occasionally the wrist loses strength because the carpal ligament is cut. Patients should undergo physical therapy after surgery to restore wrist strength. Some patients may need to adjust job duties or even change jobs after recovery from surgery.

Recurrence of carpal tunnel syndrome following treatment is rare. The majority of patients recover completely.

How can carpal tunnel syndrome be prevented?

At the workplace, workers can do on-the-job conditioning, perform stretching exercises, take frequent rest breaks, wear splints to keep wrists straight, and use correct posture and wrist position. Wearing fingerless gloves can help keep hands warm and flexible. Workstations, tools and tool handles, and tasks can be redesigned to enable the worker’s wrist to maintain a natural position during work. Jobs can be rotated among workers. Employers can develop programs in ergonomics, the process of adapting workplace conditions and job demands to the capabilities of workers. However, research has not conclusively shown that these workplace changes prevent the occurrence of carpal tunnel syndrome.

Conservative treatments include soaks, elevation, and good foot hygiene. Medical treatment is not always required. Oral antibiotics are sometimes required as a treatment. Sometimes minor toenail surgery is required.

What are ingrown toenails?

An ingrown toenail is caused by the pressure from the in growth of the nail edge into the skin of the toe. Once the edge of the nail breaks through the skin, it produces inflammation. Initially presenting as a minor discomfort, it may progress into an infection in the adjacent skin (cellulitis) and/or become a reoccurring problem. Ingrown toenails most commonly affect the large (great) toes. An ingrown toenail is medically referred to as onychocryptosis.

What are the symptoms and signs of an ingrown toenail?

Ingrown toenail symptoms and signs include redness, pain, and swelling. Sometimes there may be a clear yellowish drainage, or if it becomes infected, pus drainage. Occasionally, ingrown toenails resolve without treatment. Painful, persistent, and recurring ingrown toenails should be treated by a podiatrist.

What causes ingrown toenails?

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The main causes of an ingrown toenail are improper trimming of the toenail, an inherited or hereditary condition, and improper shoe fitting. Injury and nail picking are also common causes.

Are some people more prone to ingrown toenails?

There are a number of risk factors that may predispose a person to having an ingrown toenail. The following are some of the more common:

Athletics, particularly stop and start sports such as tennis, soccer, and basketball

Ingrown toenails most commonly occur in the large or “great toes.” However, any of the toenails can be affected on either border or side.

What causes infections in ingrown toenails?

The warm, moist environment of the feet can be a breeding ground for bacteria and fungi. These commonly include Staphylococcus,Pseudomonas, dermatophytes, Candida, and Trichophyton. When there is a break in the skin from the offending nail border, these organisms can invade the area and cause an infection. Treatment for these infections is essential to maintain healthy toenails and feet.

How do physicians diagnose an ingrown toenail?

The diagnosis of an ingrown toenail is typically straightforward. However, the signs and symptoms of ingrown toenails can vary quite dramatically, particularly if an infection develops. There may simply be some tenderness at the nail border when pressure is applied. There is typically an incurvation of the nail or a spike of nail (spicule) pressing into the skin of the nail border. Associated redness and swelling localized to the nail also suggest the diagnosis of an ingrown toenail. When an infection is involved, there may be severe redness and swelling, drainage, pus, and malodor.

Making the proper diagnosis requires taking into account the medical history and all possible causative factors. If you are unsure, seek professional help. Some conditions such as tumors, foreign bodies, trauma, and fungal infection may appear to be an ingrown toenail to the untrained eye.

What are possible complications of ingrown toenails?

An unresolving ingrown toenail can have serious consequences. A localized infection of the nail border (paronychia) can progress to a deeper soft-tissue infection (cellulitis) which can in turn progress to a bone infection (osteomyelitis). Complications can include scarring of the surrounding skin and nail borders as well as thickened, deformed (onychodystrophy) fungal toenails (onychomycosis).

How do people treat an ingrown toenail at home?

The following home-care treatments may provide temporary relief.

Lukewarm water foot soaks for 15 to 20 minutes with any one of the following options can be helpful: one part white vinegar to four parts water; 2 tablespoons Epsom salts per quart of water; or a dilute Clorox type bleach with 1/3 teaspoon of Clorox in 1 gallon of water.

Elevate the foot and leg.

Take oral anti-inflammatory drugs.

Trim the toenail straight across the top without digging into the corners or leaving them too short.

Carefully rolling back be overgrown skin at the affected nail border may allow one to slip a small piece of cotton or dental floss to lift the offending edge of the nail up from the skin.

If symptoms persist, medical treatment from a podiatrist is recommended.

When should someone seek medical treatment for an ingrown toenail?

Persons with diabetes or those who have a compromised immune system should promptly seek the care of a podiatrist/physician for ingrown toenail treatment. If home treatments are not successful within a week or there is persistent pain and/or signs of infection, podiatric medical treatment is recommended. Signs of infection can include swelling, redness, streaking, pain, and drainage that may be yellow, green, or white and purulent (containing pus).

What is the treatment for ingrown toenails?

There are various types of treatments, including self-care, soaking, avoidance of shoe pressure on the toenails, proper methods to trim the nails, and various surgical treatments. Sometimes antibiotics may be required.

What types of nail surgery are used for ingrown toenails?

Surgical treatments include the following: temporary section of the offending nail border or corner, avulsion (detachment) of the nail or offending nail border, or permanent elimination of the nail (matrixectomy) or offending nail border (partial matrixectomy). A matrixectomy is the destruction or removal the cells where the nail grows from called the nail matrix. The nail matrix is at the base of the toenail under the skin. This procedure can be done surgically by dissection, chemically, or electrically by destroying part or all of the matrix cells. These procedures are commonly reserved for chronic or recurrent situations.

Is surgery really necessary?

If conservative treatments fail, surgery to remove the offending nail border is recommended. If the condition is recurrent and/or chronic, a matrixectomy may be recommended.

How can people prevent ingrown toenails from recurring?

Avoid shoes that are too small (putting pressure on the toenail) or too large (where the foot is moving back-and-forth inside the shoe. Improperly fitting footwear can cause trauma to the toenail. Use proper methods of trimming the toenail with clean instruments and do not trim them too short.

Ingrown toenail do’s

Do wear properly fitting shoes that allow you to wiggle your toes without having your foot slide around within.

Do avoid repeated pressure and trauma to the toenails.

Do wear sport-specific shoes.

Do practice good foot hygiene.

Do trim toenails straight across.

Ingrown toenail dont’s

Don’t cut down the corners of the toenails.

Don’t trim toenails too short.

Don’t wear improperly fitting shoes.

Don’t avoid treatment by a professional if symptoms persist.

Don’t try and do surgery on the toenail yourself.

What is the prognosis for an ingrown toenail?

The prognosis for an ingrown toenail is generally very good, particularly if professional treatment is engaged when the problem does not resolve itself after a week or so and risk factors are addressed.

Definition

Frozen shoulder, also known as adhesive capsulitis, is a condition characterized by stiffness and pain in your shoulder joint. Signs and symptoms typically begin gradually, worsen over time and then resolve, usually within one or two years.

Your risk of developing frozen shoulder increases if you’re recovering from a medical condition or procedure that affects the mobility of your arm — such as a stroke or a mastectomy.

Treatment for frozen shoulder involves stretching exercises and, sometimes, the injection of corticosteroids and numbing medications into the joint capsule. In a small percentage of cases, surgery may be needed to loosen the joint capsule so that it can move more freely.

Symptoms

Frozen shoulder typically develops slowly, and in three stages. Each of these stages can last a number of months.

Painful stage. During this stage, pain occurs with any movement of your shoulder, and your shoulder’s range of motion starts to become limited.

Frozen stage. Pain may begin to diminish during this stage. However, your shoulder becomes stiffer, and your range of motion decreases notably.

Thawing stage. During the thawing stage, the range of motion in your shoulder begins to improve.

For some people, the pain worsens at night, sometimes disrupting normal sleep patterns

Causes

The bones, ligaments and tendons that make up your shoulder joint are encased in a capsule of connective tissue. Frozen shoulder occurs when this capsule thickens and tightens around the shoulder joint, restricting its movement.

Doctors aren’t sure why this happens to some people and not to others, although it’s more likely to occur in people who have recently experienced prolonged immobilization of their shoulder, such as after surgery or an arm fracture.

Risk factors

Although the exact cause is unknown, certain factors may increase your risk of developing frozen shoulder.

Age and sex

People 40 and older are more likely to experience frozen shoulder. Most of the people who develop the condition are women.

Immobility or reduced mobility

People who have experienced prolonged immobility or reduced mobility of their shoulder are at higher risk of developing frozen shoulder. Immobility may be the result of many factors, including:

Rotator cuff injury

Broken arm

Stroke

Recovery from surgery

Systemic diseases

People who have certain medical problems appear to be predisposed to develop frozen shoulder. Examples include:

Diabetes

Overactive thyroid (hyperthyroidism)

Underactive thyroid (hypothyroidism)

Cardiovascular disease

Tuberculosis

Parkinson’s disease

How is it treated?

Treatment for frozen shoulder usually starts with nonsteroidal anti-inflammatory drugs (NSAIDs) and application of heat to the affected area, followed by gentle stretching. Ice and medicines (including corticosteroid injections) may also be used to reduce pain and swelling. And physical therapy can help increase your range of motion. A frozen shoulder can take a year or more to get better.

If treatment is not helping, surgery is sometimes done to loosen some of the tight tissues around the shoulder. Two surgeries are often done. In one surgery, called manipulation under anesthesia, you are put to sleepand then your arm is moved into positions that stretch the tight tissue. The other surgery uses an arthroscope to cut through tight tissues and scar tissue. These surgeries can both be done at the same time.